SIDs, AW disorders, SIDs, AW disorders, Asthma, & Plural Asthma, & Plural

DisordersDisordersChapters: 31,32,33 & Chapters: 31,32,33 &

4343

SIDs, AW disorders, SIDs, AW disorders, Asthma, & Plural Asthma, & Plural

DisordersDisordersChapters: 31,32,33 & Chapters: 31,32,33 &

4343

Walsh Walsh E. Chavez RRT-NPSE. Chavez RRT-NPS

Definition of SIDS• Sudden and unexpected death of

an infant for which sufficient cause cannot be found by a death scene investigation, review of the history, and a postmortem

• 1week-1 year old (2-4 months < 6months)

• ALTE (Apparent life-threatening event)– Color change– Hypotonia– 70% found in the morning…..

Risk Factors • Lending for intervention

– Prone positioning– Maternal smoking– Bottle-feeding vs Breast feeding????

Normal Control of Heart Rate and Breathing

• Breathing– Brainstem

• Heart rate– Autonomic nervous system

SIDS

• Etiology:• Brainstem: controls breathing (Prematurity?) • Central Apnea & periodic breathing • Tests for assessing risk factors

– NO test that predicts risk for SIDS– Polysomnography/ pneumogram– Frequency of apnea

Polysomnography• Parameters: Pg. 547 Fig 31-3

– EEG (Brain activity)– EOG (Bilateral Eye Movement)– EMG (Muscle tone) impendence belt-EtcO2-POX/ TCOM-ECG-Ph Probe graph Figure 31-2 (pg 546)

• Laboratory Supervision: Pediatrician Who Scores?

• Setting: Pediatric Staged with Parent near

• Personnel: knowledge of the child's behavior developmental stages

Polysomnography (cont.)

• Normal sleep development:– REM and NON-REM

• Apnea (3 categories)– Rapid base line– Central: (B’sD’s andColor change) 10-25%– Obstruction:hypopnea & apnea– OB lasting >10sec or 6-8 sec (UAW OB)– Complications: Desat/ > CO2;Day time

Sleepiness, behavior changes, cor pulmonale– Treatment: – Removal of adenoidal & tonsils– NCPAP– NICU: Reflux, PofA, Hypoxia, anemia, IVH,

Seditaives, seizures, incoordiation with feedings

Home Cardiorespiratory Monitors= Apnea

Monitors• Alert the caregiver to a

cardiorespiratory abnormality• Diagnostic devices• Training• Social/parental implications

Chapter 32Chapter 32

Pediatric Airway Pediatric Airway Disorders and Parenchymal Disorders and Parenchymal

Lung DiseasesLung Diseases

Pediatric AirwayUpper airway (Pg. 555 fig. 32-1)

Above C3-4 Peds

non expandable Cricoid rings (Narrowest portion)

-obligate nose breathers 3-6 monthsPoor coronation between rr& oropharngeal motor

skills & large tonguesDevelopement up to 8 years of age• Lower airway:• Trachea > Subdivisions 17-16: adults23

generations…..RSV ?• Airway obstruction:• AP/ Lateral Neck-XRAY• Assessments: RDS, Auscultate UAW: Air movement muffled/stridor

Upper Airway Disorderslesions, inflammatory, abnormal tissue, tone

• Supralaryngeal obstruction– Choanal atresia– Pierre Robin syndrome– Deep neck infections– Tonsillar enlargement/Peritonsillar

abscess– Obstructive apnea

Upper Airway Disorders (cont.)

• Periglottic obstruction (around the glottis)

– Epiglottis– Laryngotracheobronchitis (LTB-

CROUP)

– Table 32-1 Differential Diagnosis– Pg. 559

Epiglottitis Life Threatening =Bacterial infection (H influenza

B)• Incidence and etiology

– <6 years old– Noninfectious: aspiration of hot liquid,

traumatic intubations, blind finger sweep

• Signs and symptoms: ABRUPT • Fever, soar throat, dysphagia(drooling)• MUFFLED, retractions, RDS, upright sniffing

position• Diagnosis: lateral NECk (Thumb sign) C&S, ABG

• Treatment: (small?) ETT, RSI, ceftriaxone, Extubate leak?Bronchoscope, antibotcs

Epiglottitis (cont.)

LaryngotracheobronchitisLTB-CROUP

(6 months-6 years)

• Incidence and etiology: • Parainfluenza Virus 1• Over several days

• Signs and symptoms:• Low grade fever, malasise, rhinorrhea, hoarse

voice BARKY COUGH

• Diagnosis:• Lateral neck-xray: Steeple sign

(SUBglottic)

• Treatment: Racemic Epi, hydration, temp ……………..control, humidification, Mist tents, O2,

>0.35Fio2= impending resp FailureIntubations

Laryngotracheobronchitis (cont.)

Lower Airway Disorders

• Obstruction of the trachea and major bronchi– Tracheomalacia– Congenital tracheal or bronchial

stenosis

Lower Airway Disorders pg563

• Foreign body aspiration– Incidence:

• Leading cause of accidental death – Signs and symptoms:

• Degree of AW OB• Unilateral Wheezing/ reoccurring PNA

– Diagnosis: AP CXR/neck and lateral– Laryngeal level– Hyperinflation/Ball valve effect – Bronchoscopy– Treatment:– Removal of object continue to monitor patient

Foreign Body Aspiration

Lower Airway Disorders• Atelectasis

– Etiology and pathophysiology:• Failure to reinflate

– Signs and symptoms:• Dyspnea • (Severe) V/Q mismatch • RDS

– Diagnosis: CXR, B/S, tracheal deviation– Treatment: Hyperinflation therapy,

Bronchial hygiene therapy,

Lower Airway Disorders• Bronchiectasis: • Irreversible dilation of the bronical tree

– Etiology and pathology• CF/ frequent respiratory infections• Left lower lobes mostly involved

– Signs and symptoms:• Chronic cough w/ copious amts of

purulent sputum– Diagnosis: CXR and CT– Treatment: CPT, hydration,

antibotics,

Lower Airway Disorders• Acute bronchiolitis

– Etiology: Viral Respiratory Tract infection related to RSV

– Incidence:<1 year of age with BPD, CF, PPHN & CHD

– Signs and symptoms: coryza, cough, RDS, wheezing (APNEA), dehydration

– Diagnosis:Nasal Swab: +RSV– Treatment:O2, (MV), IV, Supportive care– Prognosis: GOOD

Pneumonia• Viral

– 1st:Respiratory syncytial virus (RSV)• Coryza, NASAL CONGESTION, cough & fever• Supportive Care vs. Ribavirin

– 2nd:Parainfluenza virus Types1(LTB), 2, and 3(children<5yr)• O2 and supportive care

– Influenza virus:• Winter seasons• Vaccinations yearly

– Adenovirus:– High rates of M & M.– Overwhelming sepsis– Supportive care

Pneumonia• Bacterial

– Incidence: Compromised immune function, recurrent aspiration, malnutrition, daycare, passive cigarette

– Etiology: microorganisms colonize in the URT

– Signs and symptoms: same as viral– Diagnosis: CXR, > total band

count>1500, CRP, Blood Culture– Treatment: oral/ IV antibiotics– 7-14 days

– Pox & ABG

Chapter 33Chapter 33PG. 582-597PG. 582-597

AsthmaAsthma

Most common chronic Most common chronic childhood disease childhood disease

Pathogenesis

• Definition:Chronic inflammatory disorder of the AWs– Mast cells, eosinophils, T lympocytes,

IgE, Macrophages, neutrolphils, & epithelial cells

– Wheezing &Breathlessness

Pathogenesis of Asthma

• Pathophysiology– Chronic airway inflammation– Bronchial hyperresponsiveness– Hypersecretion of mucus

• Components of Asthma:– Inflammation -A remodeling– Bronchial constriction -Mucous plugging– AW edema -AW Hyperreponsiveness– RESULTS:

• HYPERinflation, atelectasis, hypoxia, V/Q mismatch, Hypercarbia

Risk Factors for Developing Asthma

• Allergic response:– IgE– Reversible vs. irreversible– AW remoding=fibrosis

• Environmental triggers– Intervention– Remediate & eliminate

• Tobacco• Cockroaches/ Dust mites• Molds

National Asthma Education and Prevention

Program

• Purpose:• to serve as a comprehensive tool to

diagnosis and manage asthma• Goals: Box 33-1:

– Prevent: Chronic asthma, recurrent– Maintain: NL ADLs, NL/near NL pulmonary

function– Optimal pharmacology– Meet family & patient’s expectations

Diagnosis• Medical history:

– Symptoms & triggers

• Physical examination: – History a stronger factor– Prolongs expiratory phase– RDS, Hyperexpansion

• Pulmonary function testing:– FVC, FEV1 <80% predicted, FEV1/FV(< 65%

predicted), FEF25-75%• Bronchoprovocational challenges

(methacholine 20% decrease=+test)• Exercise: running/biking

– Less sensitive HR > 170

Management

• Pharmacologic therapy– Long-term control medications

• Taken daily• Antiinflammatoryagents/ corticosteroids• Long acting B2 agonist(LABAs)

– Salmeterol & Formoterol 30-90 minutes• Methylxanthines • Leukotriene modifiers: inhibits• Cromolyn sodium (Stablizes mast cells)• Immnuomodulators: Binds to IgE

Management– Quick-relief medications: (5-15

minutes)• Short acting B-agonist last 4-6 hours• “rescue”• Anticholenergics

– Delivery systems• MDI (Spacers & holding chambers)• DPI• SVN

Management (cont.)

• Control of triggers– Identification of allergens– Avoidance and control measures– Immunotherapy

• controversial

Management (cont.)

• Peak flow monitoring– Peak flow meter– Peak flow diary– Personal best reading– Peak flow zone system

– Pg. 593

Patient and Family Education

• Asthma disease process• Medication skills• Identification and control of

triggers• Self-monitoring techniques

Managing Asthma

• Exacerbations in the ED– Assessment: PF of airflow, POX– Beta-2 agonists– Corticosteroids

Managing Asthma (cont.)

• Hospitalization and respiratory failureBOX 33-8 (Criteria for hospitalization)

– Intubation• Elective• Respiratory Fatigue

– Mechanical ventilation• Low Vt

– PS ventilation Based on the degree of sedation– I:E ratio for adequate ventilation– Prone to pneumothorases, barotrauma, per > PIP, &

hypotension

Asthma

• Exercise-induced bronchospasm (EIB)– 5-10 minutes after activity

• Asthma at school– Teachers – Self esteem

• Asthma camps– AHA

• SCAMP CAMP

Chapter 43Chapter 43Pg. 706-714Pg. 706-714

Disorders of the PleuraDisorders of the Pleura

Pleural Effusion • Clinical signs:

– Decrease in B/S, Dullness to percussion compared to the contralateral

– Tachypnea and pain• Diagnosis: CXR• Tx:Thoracentesis• Laboratory studies: Transudate vs.

Exudate, empyema (-Tube)• Causes:BOX 43-2 & 43-3 (pg. 708)• Complications: • pneumothorax• Hemorrhage• Infections

PLEURAL EFFUSION

Pneumothorax• Clinical signs:

– Chest pain & SOB– Decrease breathsounds on affected

side with hyperresonnance• Diagnosis: CXR• Treatment:

– Nitrogen washout– Needle aspiration– CT

HydroPneumothorax (cont.)

Thoracostomy Drainage

• Indications: Drainge of air/ fluid• Procedure for placement

– Conscious sedation– Role of the respiratory therapist– Assist/ Place– Drainages system (3 bottles)

Thoracostomy Drainage (cont.)

Surgery in the Pleural Space

• Treatment of empyema• Thoracoscopy • Chemical pleurodesis